Provider Demographics
NPI:1417263039
Name:THACKER, HAVIN BRENT (RPH)
Entity Type:Individual
Prefix:
First Name:HAVIN
Middle Name:BRENT
Last Name:THACKER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:BRENT
Other - Middle Name:HAVIN
Other - Last Name:THACKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:5600 BUSINESS PARK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78218-5506
Mailing Address - Country:US
Mailing Address - Phone:210-725-3344
Mailing Address - Fax:210-938-5357
Practice Address - Street 1:5600 BUSINESS PARK
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78218-5506
Practice Address - Country:US
Practice Address - Phone:210-725-3344
Practice Address - Fax:210-938-5357
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28974183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist